Implementing NICE guidance Induction of labour Implementing NICE guidance ABOUT THIS PRESENTATION: This presentation has been written to help you raise awareness of the NICE clinical guideline on Induction of labour. This guideline has been written for those responsible for providing care for women who are having or being offered induction of labour. The guideline is available in a number of formats. You can download these from the NICE website or order printed copies of the quick reference guide by calling NICE publications on 0845 003 7783 or sending an email to publications@nice.org.uk. Quote reference number N1625. You may want to hand out copies of the quick reference guide at your presentation so that your audience can refer to it. We have included notes for presenters broken down into ‘key points to raise’ for you to highlight these in your presentation and ‘additional information’ that you may want to draw on. Where necessary, the recommendation will be given in full. DISCLAIMER This slide set is an implementation tool and should be used alongside the published guidance. This information does not supersede or replace the guidance itself. 2008 NICE clinical guideline 70

Updated guidance This guideline replaces ‘Induction of labour’ (NICE inherited clinical guideline D, June 2001) This guideline is an update of a previous guideline.

What this presentation covers Scope Key priorities for implementation Costs and savings Discussion Find out more NOTES FOR PRESENTERS: In this presentation we will start by providing a definition of the guideline scope and why it is important. The NICE guideline contains 7 key priorities for implementation, which you can find in your quick reference guide. The key priorities for implementation cover the following areas: Information and decision-making – two key priorities Prevention of prolonged pregnancy – one key priority Preterm prelabour rupture of membranes – one key priority Vaginal Prostaglandin E2 ( Vaginal PGE2) – one key priority Failed induction – two key priorities Costs and savings that are likely to be incurred in implementing the guideline are summarised, followed by a suggested list of questions to help prompt discussion. Information on finding out more about the support provided by NICE is given at the end of this presentation.

Scope For induction of labour in a hospital-based maternity unit setting, this guideline covers: clinical indications, methods and timing the care and information women should be offered management of complications such as failed induction NOTES FOR PRESENTERS: Key points to raise: This guideline covers induction of labour in the following clinical circumstances: prolonged pregnancy preterm prelabour rupture of membranes prelabour rupture of membranes fetal growth restriction suspected macrosomia previous caesarean section history of precipitate labour maternal request breech presentation intrauterine fetal death Women with uncomplicated pregnancies should be given every opportunity to go into spontaneous labour. Additional Information: This guideline does not cover induction of labour for the following groups: women with diabetes women with multifetal pregnancy women having augmentation (rather than induction) of labour.

Key priorities for implementation Information and decision-making at the 38 week antenatal check when offering induction Prevention of prolonged pregnancy Preterm prelabour rupture of membranes Vaginal prostaglandin E2 (Vaginal PGE2) Failed induction NOTES FOR PRESENTERS: The NICE guideline contains lots of recommendations about how care can be improved, but the experts who wrote the guideline have chosen key recommendations that they think will have the greatest impact on care and are the most important priorities for implementation. They are divided into five areas of key priority and within these there are seven recommendations that we will consider in turn. We have also added two extra slides that give advice about women with uncomplicated pregnancies and membrane sweeping, for information.

At the 38 week antenatal check Tell women that most people will go into labour spontaneously by 42 weeks. Offer all women information about the risks associated with pregnancies that last longer than 42 weeks, and their options. NOTES FOR PRESENTERS: Key points to raise: Some women will not be interested in this information. However, if women accept, this information should cover the following options: membrane sweeping: that membrane sweeping makes spontaneous labour more likely, and so reduces the need for formal induction of labour to prevent prolonged pregnancy what a membrane sweep is that discomfort and vaginal bleeding are possible from the procedure induction of labour between 41 and 42 weeks expectant management. Additional information: The section [on information and decision-making] should be read in conjunction with ‘Antenatal care: routine care for the healthy pregnant woman’ (NICE clinical guideline 62), available from www.nice.org.uk/CG062, and ‘Intrapartum care: care of healthy women and their babies during childbirth’ (NICE clinical guideline 55), available from www.nice.org.uk/CG055. Recommendation in full: (see also 1.3.1.1 in the NICE guideline) Women should be informed that most women will go into labour spontaneously by 42 weeks. At the 38 week antenatal visit, all women should be offered information about the risks associated with pregnancies that last longer than 42 weeks, and their options. The information should cover:

When offering induction Tell women: the reasons for induction being offered when, where and how it could be carried out arrangements for support and pain relief alternative options risks, benefits and methods of induction that it may not work, and subsequent options NOTES FOR PRESENTERS: Additional Information: Healthcare professionals offering induction of labour should: allow the woman time to discuss the information with her partner before coming to a decision encourage the woman to look at a variety of sources of information invite the woman to ask questions, and encourage her to think about her options support the woman in whatever decision she makes. Recommendation in full: (see also 1.1.1.2 in the NICE guideline) Healthcare professionals should explain the following points to women being offered induction of labour: the reasons for induction being offered when, where and how induction could be carried out the arrangements for support and pain relief (recognising that women are likely to find induced labour more painful than spontaneous labour) (see also 1.6.2.1 and 1.6.2.2) the alternative options if the woman chooses not to have induction of labour the risks and benefits of induction of labour in specific circumstances and the proposed induction methods that induction may not be successful and what the woman’s options would be.

Prevention of prolonged pregnancy Women with uncomplicated pregnancies should usually be offered induction of labour between 41and 42 weeks. The exact timing should take into account the woman’s preferences and local circumstances. When a vaginal examination is carried out to assess the cervix, the opportunity should be taken to offer the woman a membrane sweep. NOTES FOR PRESENTERS: Key points to raise: The recommendation on membrane sweeping on the slide is not a key priority for implementation but is included because of its relevance to preventing prolonged pregnancy. In addition, women should be offered vaginal examinations for membrane sweeping at the 40 and 41 week antenatal visits if they haven’t had children, and at the 41 week antenatal visit if they have had children. Additional membrane sweeping may be offered if labour does not start spontaneously. If a woman chooses not to have induction of labour, her decision should be respected. Healthcare professionals should discuss the woman’s care with her from then on. Additional information: From 42 weeks, women who decline induction of labour should be offered increased antenatal monitoring consisting of at least twice‑weekly cardiotocography and ultrasound estimation of maximum amniotic pool depth. This recommendation is taken from ‘Antenatal care: routine care for the healthy pregnant woman’ (NICE clinical guideline 62). Available from www.nice.org.uk/CG062. Recommendation in full: as on slide (see also 1.2.1.2 in the NICE guideline).

Preterm prelabour rupture of membranes If this occurs after 34 weeks, the maternity team should discuss with the woman: the risks to her and her baby local availability of facilities before a decision is made about whether to induce labour, using vaginal PGE2. NOTES FOR PRESENTERS: Key points to raise: If a woman has preterm prelabour rupture of membranes, induction of labour should not be carried out before 34 weeks unless there are additional obstetric indications (for example, infection or fetal compromise). Additional information: Vaginal PGE2 has been used in UK practice for many years in women with preterm rupture of membranes. However, the summary of product characteristics (SPC) (July 2008) advises that the use of vaginal PGE2 is not recommended in women with preterm rupture of membranes. Informed consent on the use of vaginal PGE2 in this situation should therefore be obtained and documented. Recommendation in full: (see also 1.2.2.2 in the NICE guideline) If a woman has preterm prelabour rupture of membranes after 34 weeks, the maternity team should discuss the following factors with her before a decision is made about whether to induce labour, using vaginal prostaglandin E2 (PGE2)[1]: risks to the woman (for example, sepsis, possible need for caesarean section) risks to the baby (for example, sepsis, problems relating to preterm birth) local availability of neonatal intensive care facilities.

Vaginal PGE2 Vaginal PGE2 is the preferred method of induction of labour, unless there are specific clinical reasons for not using it. It should be administered as gel, tablet or controlled- release pessary. Costs may vary over time, and trusts/units should take this into consideration when prescribing vaginal PGE2. NOTES FOR PRESENTERS: Key points to raise: For doses, refer to the ‘British national formulary’. The recommended regimens are: one cycle of vaginal PGE2 tablets or gel: one dose, followed by a second dose after 6 hours if labour is not established (up to a maximum of two doses) one cycle of vaginal PGE2 controlled-release pessary: one dose over 24 hours. Additional information: Do not use: Oral PGE2, Extra-amniotic PGE2, Intravenous oxytocin, Oestrogen, Vaginal nitric oxide donors, Intravenous PGE2, Intracervical, PGE2, Hyaluronidase, Corticosteroids. Mechanical procedures (balloon catheters and laminaria tents) should not be used routinely. Explain to women that available evidence does not support: Acupuncture, homeopathy, herbal supplement, castor oil, hot baths, enemas, sexual intercourse for inducing labour. In the inpatient setting, induction of labour using vaginal PGE2 should be carried out in the morning because of higher maternal satisfaction. Recommendation in full: (see also 1.3.2.1 in the NICE guideline). Vaginal PGE2 is the preferred method of induction of labour, unless there are specific clinical reasons for not using it (in particular the risk of uterine hyperstimulation). It should be administered as a gel, tablet or controlled-release pessary. Costs may vary over time, and trusts/units should take this into consideration when prescribing PGE2. For doses, refer to the SPCs. The recommended regimens are: • one cycle of vaginal PGE2 tablets or gel: one dose, followed by a second dose after 6 hours if labour is not established (up to a maximum of two doses) • one cycle of vaginal PGE2 controlled-release pessary: one dose over 24 hours.

Failed induction If induction fails, healthcare professionals should discuss this with the woman and provide support. The woman’s condition and the pregnancy in general should be fully reassessed. Fetal wellbeing should be assessed using electronic fetal monitoring. NOTES FOR PRESENTERS: Key points to raise: Failed induction is defined as labour not starting after one cycle of treatment, as described in the previous slide. Additional information: If induction fails, decisions about further management should be made in accordance with the woman’s wishes, and should take into account the clinical circumstances. Recommendation in full: as on slide (see also 1.7.2.1 in the NICE guideline).

Failed induction The subsequent management options include: a further attempt to induce labour (the timing should depend on the clinical situation and the woman’s wishes) caesarean section. NOTES FOR PRESENTERS: Key points to raise: For women who choose caesarean section after a failed induction, recommendations in ‘Caesarean section’ (NICE clinical guideline 13) should be followed. Recommendation in full: as on slide (see also 1.7.2.3 in the NICE guideline).

Costs and savings The guideline on induction of labour is unlikely to result in a significant change in resource use in the NHS. NOTES FOR PRESENTERS: Key points to raise: Costs may vary over time, and trusts/units should take this into consideration when prescribing vaginal PGE2. Choose the lowest cost option available. Additional information: NICE has worked closely with the guideline developers and other people in the NHS to look at the major costs and savings related to implementing this guideline and found that it is unlikely to result in any significant changes based on national assumptions. However, different areas may vary from the national average and it is important to scrutinise the recommendations likely to have the most significant resource impact locally to make sure that practice matches the national average. These recommendations are: Information and decision making Women should be informed that most women will go into labour spontaneously by 42 weeks. At the 38 week antenatal visit, all women should be offered information about the risks associated with pregnancies that last longer than 42 weeks, and their options. The information should cover: membrane sweeping: that membrane sweeping makes spontaneous labour more likely, and so reduces the need for formal induction of labour to prevent prolonged pregnancy what a membrane sweep is that discomfort and vaginal bleeding are possible from the procedure induction of labour between 41+0 and 42+0 weeks expectant management (recommendation 1.1.1.1) and Vaginal PGE2 Vaginal PGE2 is the preferred method of induction of labour, unless there are specific clinical reasons for not using it (in particular the risk of uterine hyperstimulation). It should be administered as a gel, tablet or controlled-release pessary. Costs may vary over time, and trusts/units should take this into consideration when prescribing PGE2. For doses, refer to the SPCs. The recommended regimens are: one cycle of vaginal PGE2 tablets or gel: one dose, followed by a second dose after 6 hours if labour is not established (up to a maximum of two doses) one cycle of vaginal PGE2 controlled-release pessary: one dose over 24 hours (recommendation 1.3.2.1).

Discussion Does our appointment scheduling allow enough time to offer the recommended information to women? How can we improve women’s experience of induction of labour? What changes to shift patterns and booking appointments could we make to offer morning inductions? NOTES FOR PRESENTERS: These questions are suggestions that have been developed to help provide a prompt for a discussion at the end of your presentation – please edit and adapt these to suit your local situation.

Find out more Visit www.nice.org.uk/CG070 for: Other guideline formats Costing statement Audit support NOTES FOR PRESENTERS: The guideline is available in a number of formats. The quick reference guide – which summarises the guidance. The NICE guideline – which includes all of the recommendations in full. The full guideline – which includes all of the evidence and rationale. ‘Understanding NICE guidance’ – a version for patients and carers. You can download these from the NICE website or order printed copies of the quick reference guide and ‘Understanding NICE guidance’ by calling NICE publications on 0845 003 7783 or by sending an email to publications@nice.org.uk. Quote reference number N1625 for the quick reference guide or N1626 for ‘Understanding NICE guidance’. You may want to hand out copies of the quick reference guide at your presentation so that your audience can refer to it. NICE has developed tools to help organisations implement this guideline, which can be found on the NICE website. Costing statement – explains the resource impact of this guidance. Audit support – assists NHS trusts to determine how well they meet NICE recommendations.